Biomedical subjects
Publications and source records attributed to B A Grishkin.
After an aneurysmal saphenous vein graft was ligated and divided at reoperation, the proximal stump continued to enlarge, rather than occluding by thrombosis, producing an aortic pseudoaneurysm that compressed adjacent cardiac structures. Oversewing the aortosaphenous junction of ligated vein graft remnants will prevent this complication.
An anterior mediastinal mass producing extrinsic airway obstruction was successfully managed by percutaneous needle aspiration, decompressing the mass and relieving the airway obstruction. This allowed safe induction of general endotracheal anesthesia and excision of the mass by a sternotomy approach.
Chylothorax is a rare complication of thymectomy. Following thymectomy for myasthenia gravis, our patient developed bilateral chylous pleural effusions. The presence of a "mediastinal window" allowed adequate drainage with a unilateral chest tube.
Isolated right atrial compression occurred 31 months after aortic valve replacement. Aortic bleeding contained by adjacent pericardium produced a pseudoaneurysm and local atrial tamponade. Transthoracic echocardiography could not distinguish the extracardiac hematoma from an intra-atrial thrombus, temporarily misleading investigators.
Endobronchial hamartoma is a rare lesion, with only 65 cases previously reported in the English literature. An additional case is reported here. The patient was successfully treated by bronchoscopic excision of the hamartoma.
Three patients with an anomalous main coronary artery coursing between the great vessels are presented with a review of the literature. Their surgical treatment by coronary artery bypass grafting with use of the ipsilateral internal mammary artery is described with angiographic follow-up. Young patients with these anomalies, whether they are asymptomatic or have syncope, are at high risk for sudden death. Older patients with angina appear to be adequately risk stratified by thallium stress tests. For patients requiring surgical intervention, aortoplasty and coronary artery bypass grafting have both resulted in relief of symptoms, but the follow-up is limited. We suggest that coronary artery bypass grafting with an ipsilateral internal mammary artery graft to the anomalous vessel is the procedure most likely to relieve ischemia and achieve good long-term results for both symptomatic relief and survival.
Thirty-two patients undergoing coronary artery bypass grafting were studied to evaluate retrograde flow in the internal mammary artery (IMA). The left IMA pedicle was prepared in routine fashion from the level of the first rib superiorly to just distal to the IMA bifurcation. Following cannulation for cardiopulmonary bypass but before institution of extracorporeal circulation, the IMA was divided 5 mm proximal to its bifurcation and allowed to bleed freely. The flow from each end was then measured by allowing the segment to bleed for 30 seconds. The mean antegrade flow was 73 +/- 34 ml/min, and the retrograde flow was 25 +/- 17.2 ml/min. The difference between the flows was significant (p less than 0.05). Based on these data we do not recommend the retrograde IMA technique as a primary form of revascularization of the myocardium. In selected circumstances it may be used if adequate retrograde flow is demonstrated before constructing the anastomosis.
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All three isoenzymes of creatine kinase (CK), including MB, the fraction used in diagnosing acute myocardial infarction (AMI), have been found in the esophagus. Clinical reports suggest that injuries to the esophagus can cause changes in peripheral serum CK. This prospective study was designed to delineate whether esophageal dilation or major esophageal surgery would cause changes in serum CK and lactate dehydrogenase isoenzymes that might be consistent with the diagnosis of an AMI. Two groups of patients admitted to a coronary care unit were used as controls: patients with electrocardiographically proved AMI and those who had chest pain but who had AMI ruled out by sequential electrocardiograms. The coronary care unit patients had serum enzymes determined on admission, then every 8 hours for four samples, and then daily for 3 days. The surgical patients had determinations preoperatively, in recovery, every 8 hours for four samples, and daily for 5 days. The patients who had esophageal dilations had serum enzyme levels drawn before the procedure and every 8 hours for 2 days after dilation. Serum total CK and lactate dehydrogenase levels were determined by automated spectrophotometry. Isoenzyme levels were determined by agarose gel electrophoresis. The data suggest that small serum CK-MB bands that may be generated by esophageal surgery or dilation can be differentiated from those seen in AMI and that AMI can be confirmed by simultaneous analysis of serum lactate dehydrogenase isoenzymes.
One hundred seventy-four patients with bronchogenic carcinoma underwent computed tomography (CT) as part of their preoperative evaluation. Overall, CT had a sensitivity of 86%, a specificity of 78%, and an accuracy of 81% in identifying mediastinal lymph node metastases. In patients with a central tumor, the sensitivity was 93%, the specificity 74%, and the accuracy 83%. In patients with a peripheral tumor, the respective percentages were 55%, 82%, and 77%. Only 11 of 66 patients with a peripheral tumor had mediastinal metastases, and five of these patients had a normal CT scan. Conversely, 43 of 64 patients with a central tumor and mediastinal lymph node enlargement on the CT scan had unresectable disease, compared with only one of 44 patients without such enlargement. We conclude that CT is not useful in the evaluation of patients with a peripheral tumor; however, it is useful in determining which patients with a central tumor do not require a surgical staging procedure prior to thoracotomy.
This report documents the experience of the authors with two patients who had received thoracic radiation for disseminated teratocarcinomas of the testis, survived their malignancies, and subsequently developed squamous cell carcinomas of the esophagus. To the authors' knowledge, only 11 other cases of esophageal malignancies arising in patients who had received previous mediastinal irradiation have been reported in the world literature. With increasingly successful mediastinal radiation for malignant disease resulting in prolonged patient survival, an increasing number of such patients with subsequent esophageal malignancies can be anticipated. Close follow-up of patients receiving radiation therapy to periesophageal tissues is recommended, and prompt evaluation of any symptoms of esophageal dysfunction is indicated.
Two hundred fourteen patients underwent treatment for carcinoma of the esophagus between January, 1950, and July, 1978, with an over-all 5 year survival rate of 1.9%. Forty-six patients (21.5% of series) underwent esophageal resection with either esophagogastrostomy (37 patients) or colon interposition (nine patients). The operative mortality rate was 18.9% for the esophagogastrectomy group and 33% for the colon interposition patients. "Curative" resections resulted in a 14.3% 5 year survival rate. One hundred twenty-seven patients (59.3% of series) were treated by irradiation therapy, with a mean survival time of 9.6 months for patients receiving "curative" dosage (over 4,500 rads). There were no 5 year survivors in this group. Palliative procedures, such as feeding gastrostomy and palliative (less than 4,500 rads) irradiation therapy, contributed little to patient comfort or survival. We favor a palliative approach to the treatment of esophageal carcinoma and believe that, when possible, esophageal resection with esophagogastrostomy is the preferable form of therapy and offers an occasional cure.
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